The Veterans Affairs (VA) Team-Managed Home-Based Primary Care (TM/HBPC)
program is a complex model of home-based health care that includes a primary
care manager, 24-hour contact for patients, prior approval of hospital admissions,
and HBPC team participation in hospital discharge planning. In this multisite
randomized trial among 1966 patients with 2 or more activities of daily living
impairments or a terminal illness, congestive heart failure, or chronic obstructive
pulmonary disease, Hughes and colleagues found that functional status outcomes
of patients assigned to receive TM/HBPC after hospital discharge did not differ
significantly from those of patients who received customary VA and private
sector care. Improvement in most health-related quality of life measures among
patients with terminal illness was greater in the TM/HBPC group, satisfaction
with care among patients who were not terminally ill was higher, caregiver
outcomes were generally better, and hospital readmissions at 6 months were
reduced, but not at 12 months. The total mean per person costs were 6.8% higher
in the TM/HBPC group at 6 months and 12.1% higher at 12 months compared with
standard care.

The National Institutes of Health issued clinical alerts reporting the
results of 2 carotid endarterectomy clinical trials, the North American Symptomatic
Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis
Study, prior to their publication in peer-reviewed journals. Gross and colleaguesArticle
found that the monthly carotid endarterectomy rates increased promptly and
substantially after dissemination of the clinical alerts, but the changes
in practice were applied to patients and in clinical settings not supported
by the trial results. In editorials, Fontanarosa and FlanaginArticle discuss issues
surrounding prepublication release of medical research, and with DeAngelisArticle,
outline policies of THE JOURNAL regarding release of scientific information
to the public.

TB Among Foreign-Born Persons in the United States

In the United States, the number of reported cases of tuberculosis (TB)
has decreased since 1992, but this decline has occurred only among persons
born in the United States. Talbot and colleagues report that between 1993
and 1998, the number of TB cases among foreign-born persons increased 2.6%,
and the proportion of US cases that were foreign-born increased from 29.8%
to 41.6%. The TB case rate was 32.9 per 100,000 population in foreign-born
persons and 5.8 per 100,000 in US-born persons. Six states—California,
New York, Texas, Florida, New Jersey, and Illinois—reported 73.4% of
foreign-born cases.

Transient ischemic attack (TIA) is difficult to diagnose with certainty,
and the management of patients with suspected TIA varies widely. Johnston
and colleagues studied 1707 patients, mean age 72 years, with an emergency
department diagnosis of TIA. During the 90 days after the index TIA, stroke
occurred in 180 persons, 91 within the first 2 days; and stroke or other adverse
events occurred in 428 patients. Risk factors independently associated with
stroke included age older than 60 years, diabetes mellitus, symptom duration
greater than 10 minutes, weakness, and speech impairment.

Understanding why some patients with terminal illness desire a hastened
death is important to the practice of palliative care and to informed policy
on physician-assisted suicide. Among 92 patients terminally ill with cancer,
Breitbart and colleagues classified 16 patients (17%) as having a high desire
for hastened death based on the self-report Schedule of Attitudes Toward Hastened
Death. Depression and hopelessness were significant independent predictors
of the desire for hastened death.